Setting

Patients

77 patients who were 12–20 years of age, had no other health problems except for treated hypothyroidism, had been treated
with insulin for ≥1 year, had a recent glycated haemoglobin concentration (HbA1c) of 7% to 14%, had no severe hypoglycaemic events in the previous 6 months, and were in a school grade appropriate to age
within 1 year. Follow up was 97% (mean age 14 y, 57% girls, 92% white).

Intervention

42 participants were allocated to IDM plus CST and 35 were allocated to IDM alone. IDM comprised ≥3 daily insulin injections
or continuous subcutaneous insulin infusion, self monitoring of blood glucose concentrations ≥4 times daily, monthly outpatient
visits, and interim telephone contact. The CST intervention consisted of 6 weekly small group sessions (2–3 participants and
a nurse practitioner), each lasting 1–1.5 hours, and monthly follow up visits for 12 months. The sessions focused on developing
coping skills around social problem solving, social skills training, cognitive behaviour modification, and conflict resolution
through role playing (eg, managing food choices with friends) with feedback and modelling of appropriate coping behaviour
by the nurse practitioner. Follow up role playing with peers continued for 3–5 weeks to solidify the new behaviours.

Conclusion

Adolescents who received intensive diabetes management (IDM) plus a behavioural programme of coping skills training had lower
HbA1c concentrations and less negative impact of diabetes on quality of life than those who received IDM alone.

Commentary

Adolescents with diabetes have notoriously poor glycaemic control. This follow up study by Grey et al shows that they can have problems dealing with social situations that may lead to adverse glycaemic effects. It also shows
that managing these situations effectively can be learnt with CST. The authors first published their study findings at 6 months
follow up and at that time found improvements in HbA1c concentrations, self efficacy, and quality of life.1 Unlike most studies that show that the effects of an intervention drop off over time, the beneficial effects of CST persisted
at 1 year: glycaemic control in the intervention group continued to be better than that of the control group. A new finding
in this follow up study is that, unlike girls, boys in the 2 groups did not differ in hypoglycaemic episodes or being overweight.
This may be explained by differences in how boys and girls manage their illness.2

The effects on quality of life may initially seem surprising, as one might expect IDM to reduce it. However, the processes
of coping and adaptation, facilitated by CST and resulting in increased self efficacy, appear to mitigate the effects of intensive
diabetes management on quality of life.

The adolescents studied were predominantly white (95%) and most were from middle socioeconomic groups; further studies are
required to explore the effects of CST on non-white and poorer adolescents. No cost effectiveness analysis was done; such
an analysis would be helpful to those charged with deciding whether to implement a similar programme in their clinical settings.

The results are relevant for diabetes educators, clinical nurse specialists, and paediatric nurses. They support the notion
that attending to psychosocial outcomes is important, and they also show the dynamic nature of quality of life. From both
biomedical and humanistic perspectives, helping adolescents to learn to live and cope with diabetes is probably as important
as education.

CST may be a useful adjunct to the armamentarium of tools nurses can use to deal with the psychosocial aspects of diabetes.
Its use should not be limited to adolescents; adults too, may benefit from these kinds of behavioural approaches to care.